Provider Demographics
NPI:1558502294
Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Entity Type:Organization
Organization Name:RIVER EDGE BEHAVIORAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:HIERS
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-751-4507
Mailing Address - Street 1:175 EMERY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3692
Mailing Address - Country:US
Mailing Address - Phone:478-751-4507
Mailing Address - Fax:478-751-4536
Practice Address - Street 1:109 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:31044-9426
Practice Address - Country:US
Practice Address - Phone:478-751-4519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000604194AMMedicaid